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Swann-Thomsen HE, Sitts C, Hanks J, Tivis R. Implementing a social work care coordination model for children and youth with special health care needs in a rural-urban health system. SOCIAL WORK IN HEALTH CARE 2024; 63:188-204. [PMID: 38217440 DOI: 10.1080/00981389.2024.2304010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 01/05/2024] [Indexed: 01/15/2024]
Abstract
This retrospective chart review examined care coordination among pediatric patients with varying levels of medical complexity who received care in a rural-urban health system. Care coordination utilization across patient acuity levels was examined for meaningful differences in frequency and duration of care coordination services. Results indicated that patients with more severe medical complexity had increased frequency and duration of care coordination services, as well as different patterns of care coordination activity utilization. This model of pediatric outpatient care coordination provides a flexible and highly targeted approach for stratification of care and services based on the needs of the individual patient.
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Affiliation(s)
| | - Claire Sitts
- St. Luke's Children's Hospital, Boise, Idaho, USA
| | - John Hanks
- St. Luke's Children's Hospital, Boise, Idaho, USA
| | - Rick Tivis
- Applied Research Division, St. Luke's Health System, Boise, Idaho, USA
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Bouton C, Journeaux M, Jourdain M, Angibaud M, Huon JF, Rat C. Interprofessional collaboration in primary care: what effect on patient health? A systematic literature review. BMC PRIMARY CARE 2023; 24:253. [PMID: 38031014 PMCID: PMC10685527 DOI: 10.1186/s12875-023-02189-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 10/20/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND In a period of change in the organization of primary care, Interprofessional Collaboration (IPC) is presented as one of the solutions to health issues. Although the number of inter-professional interventions grounded in primary care increases in all developed countries, evidence on the effects of these collaborations on patient-centred outcomes is patchy. The objective of our study was to assess the effects of IPC grounded in the primary care setting on patient-centred outcomes. METHODS We conducted a systematic literature review using the PubMed, Embase, PsycINFO and CINAHL databases from 01/01/1995 to 01/03/2021, according to the PRISMA guidelines. Studies reporting the effects of IPC in primary care on patient health outcomes were included. The quality of the studies was assessed using the revised Downs and Black checklist. RESULTS Sixty-five articles concerning 61 interventions were analysed. A total of 43 studies were prospective and randomized. Studies were classified into 3 main categories as follows: 1) studies with patients at cardiovascular risk (28 studies)-including diabetes (18 studies) and arterial hypertension (5 studies); 2) studies including elderly and/or polypathological patients (18 studies); and 3) patients with symptoms of mental or physical disorders (15 studies). The number of included patients varied greatly (from 50 to 312,377). The proportion of studies that reported a positive effect of IPC on patient-centred outcomes was as follows: 23 out of the 28 studies including patients at cardiovascular risk, 8 out of the 18 studies of elderly or polypathological patients, and 11 out of the 12 studies of patients with mental or physical disorders. CONCLUSIONS Evidence suggests that IPC is effective in the management of patients at cardiovascular risk. In elderly or polypathological patients and in patients with mental or physical disorders, the number of studies remains very limited, and the results are heterogeneous. Researchers should be encouraged to perform studies based on comparative designs: it would increase evidence on the positive effect and benefits of IPC on patient variables.
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Affiliation(s)
- Céline Bouton
- Department of General Practice, Faculty of Medicine, University of Nantes, 1, Rue Gaston Veil, 44035, Nantes, France.
- Primary Care Federative Department, Faculty of Medicine, University of Nantes, Nantes, France.
| | - Manon Journeaux
- Department of General Practice, Faculty of Medicine, University of Nantes, 1, Rue Gaston Veil, 44035, Nantes, France
| | - Maud Jourdain
- Department of General Practice, Faculty of Medicine, University of Nantes, 1, Rue Gaston Veil, 44035, Nantes, France
- Primary Care Federative Department, Faculty of Medicine, University of Nantes, Nantes, France
| | - Morgane Angibaud
- Primary Care Federative Department, Faculty of Medicine, University of Nantes, Nantes, France
| | - Jean-François Huon
- Primary Care Federative Department, Faculty of Medicine, University of Nantes, Nantes, France
- Faculty of Pharmacy, University of Nantes, Nantes, France
| | - Cédric Rat
- Department of General Practice, Faculty of Medicine, University of Nantes, 1, Rue Gaston Veil, 44035, Nantes, France
- Primary Care Federative Department, Faculty of Medicine, University of Nantes, Nantes, France
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Coombs C, Cohen T, Duddy C, Mahtani KR, Owen E, Roberts N, Saini A, Foster AS, Park S. Primary care micro-teams: an international systematic review of patient and healthcare professional perspectives. Br J Gen Pract 2023; 73:e651-e658. [PMID: 37549994 PMCID: PMC10428005 DOI: 10.3399/bjgp.2022.0545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 04/01/2023] [Indexed: 08/09/2023] Open
Abstract
BACKGROUND International trends have shifted to creating large general practices. There is an assumption that interdisciplinary teams will increase patient accessibility and provide more cost-effective, efficient services. Micro-teams have been proposed to mitigate for some potential challenges of practice expansion, including continuity of care. AIM To review available literature and examine how micro-teams are described, and identify opportunities and limitations for patients and practice staff. DESIGN AND SETTING This was an international systematic review of studies published in English. METHOD Databases (MEDLINE, EMBASE, CINAHL, Cochrane Library, and Scopus) and grey literature were searched. Studies were included if they provided evidence about implementation of primary care micro-teams. Framework analysis was used to synthesise identified literature. The research team included a public contributor co-applicant. The authors conducted stakeholder discussions with those with and without experience of micro-team implementation. RESULTS Of the 462 studies identified, 24 documents met the inclusion criteria. Most included empirical data from healthcare professionals, describing micro-team implementation. Results included characteristics of the literature; micro-team description; range of ways micro-teams have been implemented; reported outcomes; and experiences of patients and staff. CONCLUSION The organisation of primary care has potential impact on the nature and quality of patient care, safety, and outcomes. This review contributes to current debate about care delivery and how this can impact on the experiences and outcomes of patients and staff. This analysis identifies several key opportunities and challenges for future research, policy, and practice.
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Virani SS, Newby LK, Arnold SV, Bittner V, Brewer LC, Demeter SH, Dixon DL, Fearon WF, Hess B, Johnson HM, Kazi DS, Kolte D, Kumbhani DJ, LoFaso J, Mahtta D, Mark DB, Minissian M, Navar AM, Patel AR, Piano MR, Rodriguez F, Talbot AW, Taqueti VR, Thomas RJ, van Diepen S, Wiggins B, Williams MS. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2023; 82:833-955. [PMID: 37480922 DOI: 10.1016/j.jacc.2023.04.003] [Citation(s) in RCA: 71] [Impact Index Per Article: 71.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/24/2023]
Abstract
AIM The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease." METHODS A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. STRUCTURE This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.
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Virani SS, Newby LK, Arnold SV, Bittner V, Brewer LC, Demeter SH, Dixon DL, Fearon WF, Hess B, Johnson HM, Kazi DS, Kolte D, Kumbhani DJ, LoFaso J, Mahtta D, Mark DB, Minissian M, Navar AM, Patel AR, Piano MR, Rodriguez F, Talbot AW, Taqueti VR, Thomas RJ, van Diepen S, Wiggins B, Williams MS. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation 2023; 148:e9-e119. [PMID: 37471501 DOI: 10.1161/cir.0000000000001168] [Citation(s) in RCA: 180] [Impact Index Per Article: 180.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
AIM The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease." METHODS A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. STRUCTURE This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.
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Affiliation(s)
| | | | | | | | | | | | - Dave L Dixon
- Former Joint Committee on Clinical Practice Guideline member; current member during the writing effort
| | - William F Fearon
- Society for Cardiovascular Angiography and Interventions representative
| | | | | | | | - Dhaval Kolte
- AHA/ACC Joint Committee on Clinical Data Standards
| | | | | | | | - Daniel B Mark
- Former Joint Committee on Clinical Practice Guideline member; current member during the writing effort
| | | | | | | | - Mariann R Piano
- Former Joint Committee on Clinical Practice Guideline member; current member during the writing effort
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Everett C, Christy J, Batchelder H, Morgan PA, Docherty S, Smith VA, Anderson JB, Viera A, Jackson GL. Impact of primary care usual provider type and provider interdependence on outcomes for patients with diabetes: a cohort study. BMJ Open Qual 2023; 12:e002229. [PMID: 37311623 DOI: 10.1136/bmjoq-2022-002229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 05/23/2023] [Indexed: 06/15/2023] Open
Abstract
BACKGROUND Interprofessional primary care (PC) teams are key to the provision of high-quality care. PC providers often 'share' patients (eg, a patient may see multiple providers in the same clinic), resulting in between-visit interdependence between providers. However, concern remains that PC provider interdependence will reduce quality of care, causing some organisations to hesitate in creating multiple provider teams. If PC provider teams are formalised, the PC usual provider of care (UPC) type (physician, nurse practitioner (NP) or physician assistant/associate (PA)) should be determined for patients with varying levels of medical complexity. OBJECTIVE To evaluate the impact of PC provider interdependence, UPC type and patient complexity on diabetes-specific outcomes for adult patients with diabetes. DESIGN Cohort study using electronic health record data from 26 PC practices in central North Carolina, USA. PARTICIPANTS Adult patients with diabetes (N=10 498) who received PC in 2016 and 2017. OUTCOME Testing for diabetes control, testing for lipid levels, mean glycated haemoglobin (HbA1c) values and mean low-density lipoprotein (LDL) values in 2017. RESULTS Receipt of guideline recommended testing was high (72% for HbA1c and 66% for LDL testing), HbA1c values were 7.5% and LDL values were 88.5 mg/dL. When controlling for a range of patient and panel level variables, increases in PC provider interdependence were not significantly associated with diabetes-specific outcomes. Similarly, there were no significant differences in the diabetes outcomes for patients with NP/PA UPCs when compared with physicians. The number and type of a patient's chronic conditions did impact the receipt of testing, but not average values for HbA1c and LDL. CONCLUSIONS A range of UPC types on PC multiple provider teams can deliver guideline-recommended diabetes care. However, the number and type of a patient's chronic conditions alone impacted the receipt of testing, but not average values for HbA1c and LDL.
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Affiliation(s)
- Christine Everett
- Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jacob Christy
- Family Medicine and Community Health, Duke University School of Medicine, Durham, North Carolina, USA
| | - Heather Batchelder
- Family Medicine and Community Health, Duke University School of Medicine, Durham, North Carolina, USA
| | - Perri A Morgan
- Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Family Medicine and Community Health, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Valerie A Smith
- Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
- Division of General Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| | - John B Anderson
- Family Medicine and Community Health, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Primary Care, Duke University School of Medicine, Durham, North Carolina, USA
| | - Anthony Viera
- Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Family Medicine and Community Health, Duke University School of Medicine, Durham, North Carolina, USA
| | - George L Jackson
- Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
- Petter O'Donnel Jr. School of Public Health, Unitersity of Texas Southwestern Medical Center, Dallas, TX, USA
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Casalino LP, Jung HY, Bodenheimer T, Diaz I, Chen MA, Willard-Grace R, Zhang M, Johnson P, Qian Y, O'Donnell EM, Unruh MA. The Association of Teamlets and Teams with Physician Burnout and Patient Outcomes. J Gen Intern Med 2023; 38:1384-1392. [PMID: 36441365 PMCID: PMC10160282 DOI: 10.1007/s11606-022-07894-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 10/26/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Primary care "teamlets" in which a staff member and physician consistently work together might provide a simple, cost-effective way to improve care, with or without insertion within a team. OBJECTIVE To determine the prevalence and performance of teamlets and teams. DESIGN Cross-sectional observational study linking survey responses to Medicare claims. PARTICIPANTS Six hundred eighty-eight general internists and family physicians. INTERVENTIONS Based on survey responses, physicians were assigned to one of four teamlet/team categories (e.g., teamlet/no team) and, in secondary analyses, to one of eight teamlet/team categories that classified teamlets into high, medium, and low collaboration as perceived by the physician (e.g., teamlet perceived-high collaboration/no team). MAIN MEASURES Descriptive: percentage of physicians in teamlet/team categories. OUTCOME MEASURES physician burnout; ambulatory care sensitive emergency department and hospital admissions; Medicare spending. KEY RESULTS 77.4% of physicians practiced in teamlets; 36.7% in teams. Of the four categories, 49.1% practiced in the teamlet/no team category; 28.3% in the teamlet/team category; 8.4% in no teamlet/team; 14.1% in no teamlet/no team. 15.7%, 47.4%, and 14.4% of physicians practiced in perceived high-, medium-, and low-collaboration teamlets. Physicians who practiced neither in a teamlet nor in a team had significantly lower rates of burnout compared to the three teamlet/team categories. There were no consistent, significant differences in outcomes or Medicare spending by teamlet/team or teamlet perceived-collaboration/team categories compared to no teamlet/no team, for Medicare beneficiaries in general or for dual-eligible beneficiaries. CONCLUSIONS Most general internists and family physicians practice in teamlets, and some practice in teams, but neither practicing in a teamlet, in a team, or in the two together was associated with lower physician burnout, better outcomes for patients, or lower Medicare spending. Further study is indicated to investigate whether certain types of teamlet, teams, or teamlets within teams can achieve higher performance.
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Affiliation(s)
- Lawrence P Casalino
- Department of Population Health Sciences, Weill Cornell Medical College, 402 E. 67th St. Room LA 217, New York, NY, 10065-6304, USA.
| | - Hye-Young Jung
- Department of Population Health Sciences, Weill Cornell Medical College, 402 E. 67th St. Room LA 217, New York, NY, 10065-6304, USA
| | | | - Ivan Diaz
- Department of Population Health Sciences, Weill Cornell Medical College, 402 E. 67th St. Room LA 217, New York, NY, 10065-6304, USA
| | | | | | - Manyao Zhang
- Department of Population Health Sciences, Weill Cornell Medical College, 402 E. 67th St. Room LA 217, New York, NY, 10065-6304, USA
| | - Phyllis Johnson
- Department of Population Health Sciences, Weill Cornell Medical College, 402 E. 67th St. Room LA 217, New York, NY, 10065-6304, USA
| | | | - Eloise M O'Donnell
- Department of Population Health Sciences, Weill Cornell Medical College, 402 E. 67th St. Room LA 217, New York, NY, 10065-6304, USA
| | - Mark A Unruh
- Department of Population Health Sciences, Weill Cornell Medical College, 402 E. 67th St. Room LA 217, New York, NY, 10065-6304, USA
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Li M, Tang H, Liu X. Primary care team and its association with quality of care for people with multimorbidity: a systematic review. BMC PRIMARY CARE 2023; 24:20. [PMID: 36653754 PMCID: PMC9850572 DOI: 10.1186/s12875-023-01968-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 01/03/2023] [Indexed: 01/20/2023]
Abstract
BACKGROUND Multimorbidity is posing an enormous burden to health systems, especially for primary healthcare system. While primary care teams (PCTs) are believed to have potentials to improve quality of primary health care (PHC), less is known about their impact on the quality of care for people with multimorbidity. We assessed the characteristics of PCTs and their impact on the quality of care for people with multimorbidity and the mechanisms. METHODS: We searched PubMed, MEDLINE, EMBASE, ProQuest for published studies from January 2000 to October 2021 for studies in English. Following through PRISMA guidelines, two reviewers independently abstracted data and reconciled by consensus with a third reviewer. Titles, abstracts, and full texts were evaluated to identify relevant studies. Studies were categorized by types of interventions, the impact of interventions on outcome measures, and mechanisms of interventions. RESULTS: Seventeen studies (13 RCT, 3 cohort studies, and 1 non-randomized trial) were identified. PCTs were summarized into three types-upward PCTs, downward PCTs and traditional PCTs according to the skill mix. The upward PCTs included primary care workers and specialists from upper-level hospitals, downward PCTs involving primary care workers and lay health workers, and traditional PCTs involving physicians and care managers. PCTs improved patients' mental and psychological health outcomes greatly, and also improved patients' perceptions towards care including satisfaction with care, sense of improvement, and patient-centeredness. PCTs also improved the process of care and changed providers' behaviors. However, PCTs showed mixed effects on clinical outcome measures. CONCLUSIONS PCTs have improved mental and psychological health outcomes, the process of care, patients' care experiences, and satisfaction towards care for patients with multimorbidity. The effect of PCTs on clinical outcomes and changes in patient behaviors need to be further explored.
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Affiliation(s)
- Mingyue Li
- grid.11135.370000 0001 2256 9319Department of Health Policy and Management, School of Public Health, Peking University, Beijing, China ,grid.11135.370000 0001 2256 9319China Center for Health Development Studies, Peking University, 38 Xue Yuan Road, Beijing, 100191 China
| | - Haoqing Tang
- grid.11135.370000 0001 2256 9319Department of Health Policy and Management, School of Public Health, Peking University, Beijing, China ,grid.11135.370000 0001 2256 9319China Center for Health Development Studies, Peking University, 38 Xue Yuan Road, Beijing, 100191 China
| | - Xiaoyun Liu
- grid.11135.370000 0001 2256 9319China Center for Health Development Studies, Peking University, 38 Xue Yuan Road, Beijing, 100191 China
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Everett CM, Docherty SL, Matheson E, Morgan PA, Price A, Christy J, Michener L, Smith VA, Anderson JB, Viera A, Jackson GL. Teaming up in primary care: Membership boundaries, interdependence, and coordination. JAAPA 2022; 35:1-10. [PMID: 34985006 PMCID: PMC9869344 DOI: 10.1097/01.jaa.0000805840.00477.58] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Increased demand for quality primary care and value-based payment has prompted interest in implementing primary care teams. Evidence-based recommendations for implementing teams will be critical to successful PA participation. This study sought to describe how primary care providers (PCPs) define team membership boundaries and coordinate tasks. METHODS This mixed-methods study included 28 PCPs from a primary care network. We analyzed survey data using descriptive statistics and interview data using content analysis. RESULTS Ninety-six percent of PCPs reported team membership. Team models fell into one of five categories. The predominant coordination mechanism differed by whether coordination was required in a visit or between visits. CONCLUSIONS Team-based primary care is a strategy for improving access to quality primary care. Most PCPs define team membership based on within-visit task interdependencies. Our findings suggest that team-based interventions can focus on clarifying team membership, increasing interaction between clinicians, and enhancing the electronic health record to facilitate between-visit coordination.
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Affiliation(s)
- Christine M Everett
- At Duke University in Durham, N.C., Christine M. Everett is an associate professor in the Division of PA Studies in the School of Medicine's Department of Family Medicine and Community Health and the Department of Population Health Sciences, and Sharron L. Docherty is a professor in the School of Nursing. Elaine Matheson is advanced practice provider medical director at Duke Primary Care in Durham. Perri A. Morgan is a professor in the Division of PA Studies in the Department of Family Medicine and Community Health and the Department of Population Health. In the Department of Family Medicine and Community Health, Ashley Price is a research program lead, Jacob Christy is a clinical research coordinator, and Lloyd Michener is a professor emeritus. Valerie A. Smith is an associate professor in the Department of Population Health and in the Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT) at the Durham VA Health Care System. John B. Anderson, Jr., is an associate professor in the Department of Family Medicine and Community Health and chief medical officer at Duke Primary Care. Anthony Viera is a professor and chair in the Department of Family Medicine and Community Health. George L. Jackson is a professor in the Department of Population Health, Department of Internal Medicine, Department of Family Medicine and Community Health and at ADAPT. The authors disclose that this research was supported by a grant from the National Institutes of Aging (K01AG53378). The grant funding source had no role in the design, conduct, collection, management, analysis, or interpretation of the data; or in the preparation, review, or approval of the manuscript. The authors have disclosed no other potential conflicts of interest, financial or otherwise. The views expressed in this paper are those of the authors and do not reflect the position or policy of Duke University, Duke Health System, the Department of Veterans Affairs, or the US government
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Holt SR, Tobin DG, Whitman L, Ellman M, Moriarty JP, Doolittle B. Creating a Satisfying Continuity Clinic Experience for Primary Care Trainees. Am J Med 2021; 134:547-553. [PMID: 33385340 DOI: 10.1016/j.amjmed.2020.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 12/17/2020] [Indexed: 11/16/2022]
Affiliation(s)
- Stephen R Holt
- Yale Primary Care Internal Medicine Program, Yale-New Haven Hospital, Conn.
| | - Daniel G Tobin
- St. Raphael's Adult Primary Care Center of Yale-New Haven Hospital, Conn
| | - Laura Whitman
- York Street Campus Primary Care Center of Yale-New Haven Hospital, Conn
| | - Matthew Ellman
- Yale Internal Medicine Associates, Yale School of Medicine, New Haven, Conn
| | - John P Moriarty
- Yale Primary Care Internal Medicine Program, Yale-New Haven Hospital, Conn
| | - Benjamin Doolittle
- Yale Internal Medicine-Pediatrics Residency Program, Yale School of Medicine, New Haven, Conn
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Arnett DK, Blumenthal RS, Albert MA, Buroker AB, Goldberger ZD, Hahn EJ, Himmelfarb CD, Khera A, Lloyd-Jones D, McEvoy JW, Michos ED, Miedema MD, Muñoz D, Smith SC, Virani SS, Williams KA, Yeboah J, Ziaeian B. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2019; 74:e177-e232. [PMID: 30894318 PMCID: PMC7685565 DOI: 10.1016/j.jacc.2019.03.010] [Citation(s) in RCA: 947] [Impact Index Per Article: 189.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Arnett DK, Blumenthal RS, Albert MA, Buroker AB, Goldberger ZD, Hahn EJ, Himmelfarb CD, Khera A, Lloyd-Jones D, McEvoy JW, Michos ED, Miedema MD, Muñoz D, Smith SC, Virani SS, Williams KA, Yeboah J, Ziaeian B. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2019; 74:1376-1414. [PMID: 30894319 PMCID: PMC8344373 DOI: 10.1016/j.jacc.2019.03.009] [Citation(s) in RCA: 718] [Impact Index Per Article: 143.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Geriatrics Society, the American Society of Preventive Cardiology, and the Preventive Cardiovascular Nurses Association
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Arnett DK, Blumenthal RS, Albert MA, Buroker AB, Goldberger ZD, Hahn EJ, Himmelfarb CD, Khera A, Lloyd-Jones D, McEvoy JW, Michos ED, Miedema MD, Muñoz D, Smith SC, Virani SS, Williams KA, Yeboah J, Ziaeian B. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2019; 140:e563-e595. [PMID: 30879339 PMCID: PMC8351755 DOI: 10.1161/cir.0000000000000677] [Citation(s) in RCA: 358] [Impact Index Per Article: 71.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
1. The most important way to prevent atherosclerotic vascular disease, heart failure, and atrial fibrillation is to promote a healthy lifestyle throughout life. 2. A team-based care approach is an effective strategy for the prevention of cardiovascular disease. Clinicians should evaluate the social determinants of health that affect individuals to inform treatment decisions. 3. Adults who are 40 to 75 years of age and are being evaluated for cardiovascular disease prevention should undergo 10-year atherosclerotic cardiovascular disease (ASCVD) risk estimation and have a clinician–patient risk discussion before starting on pharmacological therapy, such as antihypertensive therapy, a statin, or aspirin. The presence or absence of additional risk-enhancing factors can help guide decisions about preventive interventions in select individuals, as can coronary artery calcium scanning. 4. All adults should consume a healthy diet that emphasizes the intake of vegetables, fruits, nuts, whole grains, lean vegetable or animal protein, and fish and minimizes the intake of trans fats, processed meats, refined carbohydrates, and sweetened beverages. For adults with overweight and obesity, counseling and caloric restriction are recommended for achieving and maintaining weight loss. 5. Adults should engage in at least 150 minutes per week of accumulated moderate-intensity physical activity or 75 minutes per week of vigorous-intensity physical activity. 6. For adults with type 2 diabetes mellitus, lifestyle changes, such as improving dietary habits and achieving exercise recommendations are crucial. If medication is indicated, metformin is first-line therapy, followed by consideration of a sodium-glucose cotransporter 2 inhibitor or a glucagon-like peptide-1 receptor agonist. 7. All adults should be assessed at every healthcare visit for tobacco use, and those who use tobacco should be assisted and strongly advised to quit. 8. Aspirin should be used infrequently in the routine primary prevention of ASCVD because of lack of net benefit. 9. Statin therapy is first-line treatment for primary prevention of ASCVD in patients with elevated low-density lipoprotein cholesterol levels (≥190 mg/dL), those with diabetes mellitus, who are 40 to 75 years of age, and those determined to be at sufficient ASCVD risk after a clinician–patient risk discussion. 10. Nonpharmacological interventions are recommended for all adults with elevated blood pressure or hypertension. For those requiring pharmacological therapy, the target blood pressure should generally be <130/80 mm Hg.
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Arnett DK, Blumenthal RS, Albert MA, Buroker AB, Goldberger ZD, Hahn EJ, Himmelfarb CD, Khera A, Lloyd-Jones D, McEvoy JW, Michos ED, Miedema MD, Muñoz D, Smith SC, Virani SS, Williams KA, Yeboah J, Ziaeian B. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2019; 140:e596-e646. [PMID: 30879355 PMCID: PMC7734661 DOI: 10.1161/cir.0000000000000678] [Citation(s) in RCA: 1366] [Impact Index Per Article: 273.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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15
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Gao Y, Peterson E, Pagidipati N. Opportunities for improving use of evidence-based therapy in patients with type 2 diabetes and cardiovascular disease. Clin Cardiol 2019; 42:1063-1070. [PMID: 31448852 PMCID: PMC6837027 DOI: 10.1002/clc.23252] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Accepted: 08/20/2019] [Indexed: 12/30/2022] Open
Abstract
Evidence‐based therapy that target hyperlipidemia, hypertension, smoking cessation, and weight loss have demonstrated significant benefits in reducing cardiovascular risks and related events. Although the benefit of intensively lowering blood glucose is unclear, newer antidiabetic drugs (glucagon‐like peptide‐1 receptor agonists and sodium‐glucose cotransporter‐2 inhibitors) have shown cardiovascular benefits in addition to their antihyperglycemic effect. Yet, studies suggest that recent use of evidence‐based therapy and management of cardiovascular risk among individuals with type 2 diabetes (T2D) and cardiovascular disease (CVD) remains largely suboptimal. The following narrative review first identifies barriers to translating research evidence to clinical practice at the levels of provider, health system, patient, and cost. Then it synthesizes previous implementation strategies that addressed multifaceted barriers and attempted to improve care for patients with T2D and CVD. In conclusion, team‐based care coordination, reminding systems in combination to pharmacist consultation and patient education, provider education compatible with clinical workflow, and coupled incentives between providers and patients appeared to be effective in reducing cardiovascular risks for patients with T2D and CVD, though the scalability and long‐term clinical effect of these strategies as well as the possibility of interventions involving payers and health systems remain uncertain.
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Affiliation(s)
- Yumin Gao
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Eric Peterson
- Department of Medicine, Duke Clinical Research Institute, Center for Preventive Medicine, Duke University, Durham, North Carolina
| | - Neha Pagidipati
- Department of Medicine, Duke Clinical Research Institute, Center for Preventive Medicine, Duke University, Durham, North Carolina
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16
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Kolko DJ, Torres E, Rumbarger K, James E, Turchi R, Bumgardner C, O'Brien C. Integrated Pediatric Health Care in Pennsylvania: A Survey of Primary Care and Behavioral Health Providers. Clin Pediatr (Phila) 2019; 58:213-225. [PMID: 30450951 DOI: 10.1177/0009922818810881] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study reports on a statewide survey of medical and behavioral health professionals to advance the knowledge base on the benefits and obstacles to delivering integrated pediatric health care. Surveys distributed in 3 statewide provider networks were completed by 110 behavioral health specialists (BHSs) and 111 primary care physicians (PCPs). Survey content documented their perceptions about key services, benefits, barriers, and needed opportunities related to integrated care. Factor analyses identified 8 factors, and other items were examined individually. We compared responses by specialty group (BHS vs PCP) and integrated care experience (no vs yes). The findings revealed differences across domains by specialty subgroup. In several cases, BHS (vs PCP) respondents, especially those with integrated care experience, reported lower benefits, higher barriers, and fewer resource requests. The implications of these results for enhancing care integration development, delivery, training, and research are discussed along with the study's limitations and empirical literature.
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Affiliation(s)
- David J Kolko
- 1 University of Pittsburgh School of Medicine, Psychiatry, Pittsburgh, PA, USA.,2 UPMC Western Psychiatric Hospital, Pittsburgh, PA, USA
| | - Eunice Torres
- 2 UPMC Western Psychiatric Hospital, Pittsburgh, PA, USA
| | | | - Everette James
- 3 University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Renee Turchi
- 4 Drexel University Dornsife School of Public Health, Philadelphia, PA, USA.,5 Drexel University College of Medicine, Philadelphia, PA, USA.,6 St Christopher's Hospital for Children, Philadelphia, PA, USA
| | - Cheryl Bumgardner
- 7 Pennsylvania Association of Community Health Centers, Wormleysburg, PA, USA
| | - Connell O'Brien
- 8 Rehabilitation and Community Providers Association, Harrisburg, PA, USA
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Yeoh EK, Wong MCS, Wong ELY, Yam C, Poon CM, Chung RY, Chong M, Fang Y, Wang HHX, Liang M, Cheung WWL, Chan CH, Zee B, Coats AJS. Benefits and limitations of implementing Chronic Care Model (CCM) in primary care programs: A systematic review. Int J Cardiol 2018; 258:279-288. [PMID: 29544944 DOI: 10.1016/j.ijcard.2017.11.057] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 11/07/2017] [Accepted: 11/16/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND Chronic Care Model (CCM) has been developed to improve patients' health care by restructuring health systems in a multidimensional manner. This systematic review aims to summarize and analyse programs specifically designed and conducted for the fulfilment of multiple CCM components. We have focused on programs targeting diabetes mellitus, hypertension and cardiovascular disease. METHOD AND RESULTS This review was based on a comprehensive literature search of articles in the PubMed database that reported clinical outcomes. We included a total of 25 eligible articles. Evidence of improvement in medical outcomes and the compliance of patients with medical treatment were reported in 18 and 14 studies, respectively. Two studies demonstrated a reduction of the medical burden in terms of health service utilization, and another two studies reported the effectiveness of the programs in reducing the risk of heart failure and other cardiovascular diseases. However, CCMs were still restricted by limited academic robustness and social constraints when they were implemented in primary care. Higher professional recognition, tighter system collaborations and increased financial support may be necessary to overcome the limitations of, and barriers to CCM implementation. CONCLUSION This review has identified the benefits of implementing CCM, and recommended suggestions for the future development of CCM.
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Affiliation(s)
- E K Yeoh
- School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong
| | - Martin C S Wong
- School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong
| | - Eliza L Y Wong
- School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong
| | - Carrie Yam
- School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong
| | - C M Poon
- School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong
| | - Roger Y Chung
- School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong
| | - Marc Chong
- School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong
| | - Yuan Fang
- School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong
| | - Harry H X Wang
- School of Public Health, Sun Yat-Sen University, Guangzhou, PR China; General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Miaoyin Liang
- School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong
| | - Wilson W L Cheung
- School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong
| | - Chun Hei Chan
- School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong
| | - Benny Zee
- School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong
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18
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Haggerty J, Fortin M, Breton M. Snapshot of the primary care waiting room: Informing practice redesign to align with the Patient's Medical Home model. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2018; 64:e407-e413. [PMID: 30209115 PMCID: PMC6135124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To describe the demographic characteristics, health, and health care experiences of adult patients in primary care waiting rooms in Quebec, and to determine which pillars of the Patient's Medical Home (PMH) are a priority to align primary care practices with the PMH model. DESIGN Baseline survey of a prospective cohort study using self-administered on-site and mailed questionnaires. SETTING Twelve primary care clinics within the geographic boundaries of 4 local health care networks in metropolitan, urban, rural, and remote settings in Quebec. PARTICIPANTS A total of 1029 adult patients aged between 25 and 75 who were selected during a 1-week period in the 12 primary care clinics; 789 returned questionnaires. MAIN OUTCOME MEASURES Patients' health profiles, health behaviour patterns, reasons for the visit, and health care experiences. RESULTS In this 2010 snapshot, 66.8% of patients waited longer than 2 weeks for their appointment, 71.0% of visits were for routine or follow-up care, and longer wait times and patient multimorbidity correlated with more reasons for the visit. After the visit, most patients reported being able to express their most important needs and that the doctor listened well; however, only 28.1% reported that the doctor had explored whether the recommendations would be realistic for them, and only 18.0% indicated that the doctor had explored the personal or family dimensions that affected their health. Among all patients, 56.9% reported having at least 3 chronic conditions (multimorbidity), and 30.3% reported having high or moderate levels of psychological distress. When describing their financial status, 30.7% of patients indicated it was "poor to squeezed or tight." Slightly more than half of patients did not have complementary private health insurance to cover costs of psychological services. CONCLUSION In this study, the 4 priority pillars for practices to align with the PMH were timely access, team-based care, comprehensive care, and a patient-centred approach. Widespread implementation of advanced access is an urgent priority in light of persisting difficulties in timely access. Team-based and comprehensive care are needed to address the high prevalence of multimorbidity and psychological distress and to support health behaviour change. Finally, the patient-centred approach needs to underpin every care encounter.
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Affiliation(s)
- Jeannie Haggerty
- Health services epidemiologist in Montreal, Que, Full Professor in the Department of Family Medicine at McGill University in Montreal, and McGill Chair in Family and Community Medicine at St Mary's Hospital in Montreal.
| | - Martin Fortin
- Family physician in the Family Medicine Unit at the Chicoutimi Health and Social Services Center and at the Centre intégré universitaire de santé et de services sociaux du Saguenay-Lac-Saint-Jean in Quebec, Full Professor in the Department of Family Medicine and Emergency Medicine at the Université de Sherbrooke in Quebec, and Research Chair on Chronic Diseases in Primary Care
| | - Mylaine Breton
- Associate Professor in the Department of Community Health Sciences in the Université de Sherbrooke in Quebec, and Canada Research Chair in Clinical Governance on Primary Health Care
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19
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Gastala NM, Wingrove PM, Gaglioti AH, Liaw W, Bazemore A. The Growing Trend of Health Coaches in Team-Based Primary Care Training A Multicenter Pilot Study. Fam Med 2018; 50:526-530. [PMID: 30005115 PMCID: PMC6378695 DOI: 10.22454/fammed.2018.459897] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND AND OBJECTIVES Team-based care with health coaches has improved the quality and cost effectiveness of chronic disease management and prevention. Clinical health coaches partner with patients to identify health goals, create action plans, overcome barriers to change, reinforce physician recommendations, and coordinate care. It is important to train resident physicians to practice in team-based settings. To date, there have been no studies of resident family physician exposure to health coaches. METHODS We surveyed 465 residency directors through a larger omnibus survey sent out by CERA; the response rate was 53.7%. Directors were asked about resident exposure to health coaches, the types of patients seen by health coaches, and the training background of the health coaches. We used chi-square tests to examine the relationship among these variables and program characteristics including status as a patient-centered medical home. RESULTS Almost two-thirds of the programs reported at least some residents had exposure to health coaches. Residents who trained in continuity sites with a PCMH certification of level 3 were more likely to have any exposure to health coaches (P<.05). There were multiple significant relationships between populations of patients seen and the training background of health coaches. CONCLUSIONS To improve quality, reduce costs, and become more patient centered, primary care is rapidly transforming into a team sport with a broadening roster of new players, including health coaches. This study documents positive rates of resident exposure to health coaches but also great variability in types and amount of exposure that merit further investigation and exploration of ways to grow family medicine residency contact with a diversifying practice team.
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Affiliation(s)
- Nicole M Gastala
- University of Illinois Health Mile Square Community Health Center, Chicago, IL
| | | | - Anne H Gaglioti
- National Center for Primary Care-Morehouse school of Medicine, Atlanta, GA
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20
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Lozano P, Houtrow A. Supporting Self-Management in Children and Adolescents With Complex Chronic Conditions. Pediatrics 2018; 141:S233-S241. [PMID: 29496974 DOI: 10.1542/peds.2017-1284h] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/01/2017] [Indexed: 11/24/2022] Open
Abstract
Self-management improves health outcomes in chronic illness not only by improving adherence to the treatment plan but also by building the individual's capacity to navigate challenges and solve problems. Support for self-management is a critical need among children and adolescents with (medically and/or socially) complex chronic conditions. Self-management support refers to services that health systems and community agencies provide to persons with chronic illness and their families to facilitate self-management; it is a collaboration between the patient, family, and care providers. Evidence has guided the development of self-management support approaches and tools for adults and has led to an increased adoption of best practices in adult chronic illness care. However, adult models fail to account for some key differences between children and adults, namely, the integral role of parents and/or caregivers and youth development over time. There is a need for self-management support models that take into account the developmental trajectory across the pediatric age range. Effective approaches must also recognize that in pediatrics, self-management is really shared management between the youth and the parent(s) and/or caregiver(s). Health systems should design care to address self-management for pediatric patients. Although clinicians recognize the importance of self-management in youth with complex chronic conditions, they need standardized approaches and tools to do the following: assess the self-management skills of youth and families, assess modifiable environmental influences on chronic conditions, collaboratively set self-management goals, promote competence and eventual autonomy in youth, share the responsibility for self-management support among nonphysician members of the health care team, and leverage community resources for self-management support.
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Affiliation(s)
- Paula Lozano
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington; and
| | - Amy Houtrow
- Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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21
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Kuo DZ, McAllister JW, Rossignol L, Turchi RM, Stille CJ. Care Coordination for Children With Medical Complexity: Whose Care Is It, Anyway? Pediatrics 2018; 141:S224-S232. [PMID: 29496973 DOI: 10.1542/peds.2017-1284g] [Citation(s) in RCA: 104] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/03/2017] [Indexed: 11/24/2022] Open
Abstract
Children with medical complexity (CMC) have multiple chronic conditions and require an array of medical- and community-based providers. Dedicated care coordination is increasingly seen as key to addressing the fragmented care that CMC often encounter. Often conceptually misunderstood, care coordination is a team-driven activity that organizes and drives service integration. In this article, we examine models of care coordination and clarify related terms such as care integration and case management. The location of care coordination resources for CMC may range from direct practice provision to external organizations such as hospitals and accountable care organizations. We discuss the need for infrastructure building, design and implementation leadership, use of care coordination tools and training modules, and appropriate resource allocation under new payment models.
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Affiliation(s)
- Dennis Z Kuo
- Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York;
| | - Jeanne W McAllister
- Department of Pediatrics, School of Medicine, Indiana University, Indianapolis, Indiana
| | - Lisa Rossignol
- The New Mexico Disability Story, Albuquerque, New Mexico
| | - Renee M Turchi
- Department of Pediatrics, St. Christopher's Hospital for Children and Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania; and
| | - Christopher J Stille
- Department of Pediatrics, School of Medicine, University of Colorado Denver, Denver, Colorado
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22
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Cost Estimates for Designing and Implementing a Novel Team Care Model for Chronically Ill Patients. J Ambul Care Manage 2017; 41:58-70. [PMID: 28952982 DOI: 10.1097/jac.0000000000000209] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Little is known about the cost of implementing chronic care models. We estimate the human resource cost of implementing a novel team-based chronic care model "Champion," at a large multispecialty group practice. We used activity-based costing to calculate costs from development through rollout and stabilization in 1 clinic with 12 000 chronic care patients. Data analyzed included Microsoft Outlook meeting metadata, supporting documents, and 2014 employee wages. Implementation took more than 29 months, involved 168 employees, and cost the organization $2 304 787. Payers may need to consider a mixed-payment model to support the both implementation and maintenance costs of team-based chronic care.
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Gonzalez CA, Gentile NE, Angstman KB, Craner JR, Bonacci RP. The Associations Between Preceptor Team Lead Relationships and Resident Wellness in an Academic Medicine Setting: An Exploratory Study. PRIMER : PEER-REVIEW REPORTS IN MEDICAL EDUCATION RESEARCH 2017; 1:5. [PMID: 32944691 DOI: 10.22454/primer.2017.1.5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Background Lack of wellness among physicians has been associated with increased risk for physical and mental illness, interpersonal discord, and occupational liability. In academic primary care practices, physician wellness and self-care behaviors have been associated with improved patient outcomes. With the increase in team-based care structures in primary care clinics and residencies there may be opportunities to promote wellness among primary clinicians, particularly among resident physicians who are at increased risk for decreased well being. The primary objective of the study was to test an a priori hypothesis that family medicine residents' perception of support from preceptor team leads would be associated with well being. A secondary objective of the study was to test a post hoc hypothesis that examined whether the relationship between residents' perception of support from their preceptor team leads would be associated with residents' well being, while controlling for self-care behaviors. Methods Our study utilized a prospective cross-sectional design with purposive sampling to survey family medicine residents. Data were collected in February 2016. The survey was sent out to 58 family medicine residents across three family medicine residencies at Mayo Clinic. The survey response rate was 55% (n=32); Ten (31.3%) residents reported being in their PGY-1, 11 (34.4%) in PGY-2; and 11 (34.4%) in PGY-3; participants included 19 (59.4%) women and 13 (40.6%) men. The Brief Resident Wellness Profile (BRWP) was utilized to assess family medicine residents' perceived sense of professional accomplishment and mood in the past week. Results In bivariate correlational analyses, increased perception of support from preceptor team leads (r=.40, P<.01) and reporting a male gender (r=.43, P<.01) was associated with increased resident wellness. In exploratory multivariate analysis, results suggested that while controlling for gender, frequency of self-care behaviors, and perceived preceptor team lead support, a one-point change on rating of perceived team leader support is associated with a 1.69 increase in resident wellness score on the BRWP. Conclusions Our results provide preliminary evidence to support the relationship between preceptor team lead support and resident wellness in team-based care, above and beyond the impact that self-behaviors have on wellness. Our findings suggest evidence for the subsequent study of the impact of preceptor team lead relationship quality on resident wellness.
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Affiliation(s)
- Cesar A Gonzalez
- Departments of Psychiatry, Psychology, and Family Medicine, College of Medicine, Mayo Clinic, Rochester, MN
| | - Natalie E Gentile
- Department of Family Medicine, College of Medicine, Mayo Clinic, Rochester, MN
| | - Kurt B Angstman
- Department of Family Medicine, College of Medicine, Mayo Clinic, Rochester, MN
| | - Julia R Craner
- Division of Psychiatry and Behavioral Medicine, Spectrum Health Medical Group, and College of Human Medicine, Michigan State University, Grand Rapids, MI
| | - Robert P Bonacci
- Department of Family Medicine, College of Medicine, Mayo Clinic, Rochester, MN
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24
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Fisher EB, Boothroyd RI, Elstad EA, Hays L, Henes A, Maslow GR, Velicer C. Peer support of complex health behaviors in prevention and disease management with special reference to diabetes: systematic reviews. Clin Diabetes Endocrinol 2017; 3:4. [PMID: 28702258 PMCID: PMC5471959 DOI: 10.1186/s40842-017-0042-3] [Citation(s) in RCA: 98] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Accepted: 05/09/2017] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES Examine Peer Support (PS) for complex, sustained health behaviors in prevention or disease management with emphasis on diabetes prevention and management. DATA SOURCES AND ELIGIBILITY PS was defined as emotional, motivational and practical assistance provided by nonprofessionals for complex health behaviors. Initial review examined 65 studies drawn from 1442 abstracts identified through PubMed, published 1/1/2000-7/15/2011. From this search, 24 reviews were also identified. Extension of the search in diabetes identified 30 studies published 1/1/2000-12/31/2015. RESULTS In initial review, 54 of all 65 studies (83.1%) reported significant impacts of PS, 40 (61.5%) reporting between-group differences and another 14 (21.5%) reporting significant within-group changes. Across 19 of 24 reviews providing quantifiable findings, a median of 64.5% of studies reviewed reported significant effects of PS. In extended review of diabetes, 26 of all 30 studies (86.7%) reported significant impacts of PS, 17 (56.7%) reporting between-group differences and another nine (30.0%) reporting significant within-group changes. Among 19 of these 30 reporting HbA1c data, average reduction was 0.76 points. Studies that did not find effects of PS included other sources of support, implementation or methodological problems, lack of acceptance of interventions, poor fit to recipient needs, and possible harm of unmoderated PS. CONCLUSIONS Across diverse settings, including under-resourced countries and health care systems, PS is effective in improving complex health behaviors in disease prevention and management including in diabetes.
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Affiliation(s)
- Edwin B. Fisher
- Peers for Progress, Gillings School of Global Public Health, University of North Carolina, Box 7440, Chapel Hill, NC 27599-7440 USA
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Box 7440, Chapel Hill, NC 27599-7440 USA
| | - Renée I. Boothroyd
- Frank Porter Graham Child Development Institute, University of North Carolina, Chapel Hill, NC USA
| | | | - Laura Hays
- Indiana University School of Nursing, Indianapolis, IN USA
| | - Amy Henes
- RTI International, Research Triangle Park, NC USA
| | - Gary R. Maslow
- Department of Pediatrics, Duke University, Durham, NC USA
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC USA
| | - Clayton Velicer
- National Public Relations and Communications, Kaiser Permanente, Oakland, CA USA
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25
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Workflow standardization of a novel team care model to improve chronic care: a quasi-experimental study. BMC Health Serv Res 2017; 17:286. [PMID: 28420376 PMCID: PMC5395876 DOI: 10.1186/s12913-017-2240-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 04/10/2017] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Team-based chronic care models have not been widely adopted in community settings, partly due to their varying effectiveness in randomized control trials, implementation challenges, and concerns about physician acceptance. The Palo Alto Medical Foundation designed and implemented "Champion," a novel team-based model that includes new standard work (e.g. proactive patient outreach, pre-visit schedule grooming, depression screening, care planning, health coaching) to support patients' self-management of hypertension and diabetes. We investigated whether Champion improved clinical outcomes. METHODS We conducted a quasi-experimental study comparing the Champion clinic-level intervention (n = 38 physicians) with a usual care clinic (n = 37 physicians) in Northern California. The primary outcomes, blood pressure and glycohemoglobin (A1c), were analyzed using a piecewise linear growth curve model for patients exposed to a Champion physician visit (n = 3156) or usual care visit (n = 8034) in the two years prior and one year post implementation. Secondary outcomes were provider experience, compared at baseline and 12 months in both the intervention and usual care clinics using multi-level ordered logistic modeling, and electronic health record based fidelity measures. RESULTS Compared to usual care, in the first 6 months after a Champion physician visit, diabetes patients aged 18-75 experienced an additional -1.13 mm Hg (95% CI: -2.23 to -0.04) decline in diastolic blood pressure and -0.47 (95% CI: -0.61 to -0.33) decline in A1c. There were no additional improvements in blood pressure or A1c 6 to 12 months post physician visit. At 12 months, Champion physicians reported improved experience with managing chronic care patients in 6 of 7 survey items (p < 0.05), but compared to usual, this difference was only statistically significant for one item (p < 0.05). Fidelity to standard work was uneven; depression screening was the most commonly documented element (85% of patients), while care plans were the least (30.8% of patients). CONCLUSIONS Champion standard work improved glycemic control over the first 6 months and physicians' experience with managing chronic care; changes in blood pressure were not clinically meaningful. Our results suggest the need to understand the relationship between the intervention, the contextual features of implementation, and fidelity to further improve chronic disease outcomes. This study was retrospectively registered with the ISRCTN Registry on March 15, 2017 (ISRCTN11341906).
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Chapman SA, Blash LK. New Roles for Medical Assistants in Innovative Primary Care Practices. Health Serv Res 2016; 52 Suppl 1:383-406. [PMID: 27859097 DOI: 10.1111/1475-6773.12602] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To identify and describe new roles for medical assistants (MAs) in innovative care models that improve care while providing training and career advancement opportunities for MAs. DATA SOURCES/STUDY SETTING Primary data collected at 15 case study sites; 173 key informant interviews and de-identified secondary data on staffing, wages, patient satisfaction, and health outcomes. STUDY DESIGN Researchers used snowball sampling and screening calls to identify 15 organizations using MAs in new roles. Conducted site visits from 2010 to 2012 and updated information in 2014. DATA COLLECTION/EXTRACTION METHODS Thematic analysis explored key topics: factors driving MA role innovation, role description, training required, and wage gains. Categorized outcome data in patient and staff satisfaction, quality of care, and efficiency. PRINCIPAL FINDINGS New MA roles included health coach, medical scribe, dual role translator, health navigator, panel manager, cross-trained flexible role, and supervisor. Implementation of new roles required extensive training. MA incentives and enhanced compensation varied by role type. CONCLUSIONS New MA roles are part of a larger attempt to reform workflow and relieve primary care providers. Despite some evidence of success, spread has been limited. Key challenges to adoption included leadership and provider resistance to change, cost of additional MA training, and lack of reimbursement for nonbillable services.
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Affiliation(s)
- Susan A Chapman
- Department of Social and Behavioral Sciences, UCSF School of Nursing, Healthforce Center, Philip R. Lee Institute for Health Policy Studies, San Francisco, CA
| | - Lisel K Blash
- UCSF Healthforce Center and Philip R. Lee Institute for Health Policy Studies, San Francisco, CA
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Abstract
This update of the 2008 statement from the American Academy of Pediatrics redirects the discussion of quality health care from the theoretical to the practical within the medical home. This statement reviews the evolution of the medical home concept and challenges the provision of quality adolescent health care within the patient-centered medical home. Areas of attention for quality adolescent health care are reviewed, including developmentally appropriate care, confidentiality, location of adolescent care, providers who offer such care, the role of research in advancing care, and the transition to adult care.
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Dillon E, Panattoni L, Meehan A, Chuang J, Wilson C, Tai-Seale M. Using Unlicensed Health Coaches to Improve Care for Insured Patients with Diabetes and Hypertension: Patient and Physician Perspectives on Recruitment and Uptake. Popul Health Manag 2015; 19:332-40. [PMID: 26674597 DOI: 10.1089/pop.2015.0095] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Health coach programs using low-cost unlicensed providers have largely targeted uninsured or underserved populations, raising questions about uptake and effectiveness for insured patients. This observational study evaluated the referral process, uptake, and effectiveness of a health coach program for patients with diabetes and/or hypertension at a multispecialty clinic. Data included appointment observations; interviews with patients, physicians, and health coaches; patient and physician characteristics; and measures of utilization and clinical outcomes. Out of 1313 eligible patients, 308 (23.5%) were referred over a 12-month period and 169 (54.9%) had at least 1 health coach appointment. Although the health coach program did not change patients' biometrics, physicians and patients reported improved care processes and reduced physician workload. Barriers to enrollment included variability in physician referral practices, patient willingness, and scheduling difficulties. Modifications to physician and health coach workflow are needed to determine the program's true effectiveness.
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Affiliation(s)
- Ellis Dillon
- 1 Palo Alto Medical Foundation Research Institute , Mountain View, California
| | | | - Amy Meehan
- 1 Palo Alto Medical Foundation Research Institute , Mountain View, California
| | - Judith Chuang
- 1 Palo Alto Medical Foundation Research Institute , Mountain View, California
| | - Caroline Wilson
- 1 Palo Alto Medical Foundation Research Institute , Mountain View, California
| | - Ming Tai-Seale
- 1 Palo Alto Medical Foundation Research Institute , Mountain View, California
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Campbell EA, Crowley MJ, Powers BJ, Sanders LL, Olsen MK, Danus S, McNeill DB, Zaas AK. Diabetes Quality of Care Before and After Implementation of a Resident Clinic Practice Partnership System. Am J Med Qual 2015; 32:66-72. [PMID: 26602515 DOI: 10.1177/1062860615615210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Deficiencies in resident diabetes care quality may relate to continuity clinic design. This retrospective analysis compared diabetes care processes and outcomes within a traditional resident continuity clinic structure (2005) and after the implementation of a practice partnership system (PPS; 2009). Under PPS, patients were more likely to receive annual foot examinations (odds ratio [OR] = 11.6; 95% confidence interval [CI] = 7.2, 18.5), microalbumin screening (OR = 2.4; 95% CI = 1.6, 3.4), and aspirin use counseling (OR = 3.8; 95% CI = 2.5, 6.0) and were less likely to receive eye examinations (OR = 0.54; 95% CI = 0.36, 0.82). Hemoglobin A1c and lipid testing were similar between periods, and there was no difference in achievement of diabetes and blood pressure goals. Patients were less likely to achieve cholesterol goals under PPS (OR = 0.62; 95% CI = 0.39, 0.98). Resident practice partnerships may improve processes of diabetes care but may not affect intermediate outcomes.
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van Deventer C. Integration of non-communicable chronic diseases (NCDs) and HIV/AIDS and mental health care through the involvement of chronically ill patients using empowerment evaluation. S Afr Fam Pract (2004) 2015. [DOI: 10.1080/20786190.2015.1102499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Chapman SA, Marks A, Dower C. Positioning Medical Assistants for a Greater Role in the Era of Health Reform. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2015; 90:1347-1352. [PMID: 26039141 DOI: 10.1097/acm.0000000000000775] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Medical assistants (MAs) are one of the fastest-growing occupations in the United States. As of 2014 there were about 585,000 MAs in the United States, and the Bureau of Labor Statistics projected the MA workforce to grow by 29% from 2012 to 2022. The MA population is primarily female, ethnically and racially diverse, and paid about $15.01 per hour. MAs are primarily educated in private schools, many at for-profit institutions. The MA curriculum and length of training can be quite varied and can lead to uneven preparation for practice. Traditionally, the MA role has involved a limited clinical role and little involvement with team care, particularly in larger practices or clinics. Medical groups, clinics, and health systems are now taking a new look at MAs and how they can play a greater role in reforming health care delivery models. Expanded roles for MAs might include health coach, referral coordinator, disease registry manager, and health screener using protocols. In expanding MA roles, education and regulatory issues need to be addressed by the provider community including current inconsistent regulation and certification requirements and the lack of preparation for expanded roles in traditional MA training programs. MAs are well positioned to help address challenges in the health care delivery system including improving access to care while reducing overall cost. Successful model practices using MAs in expanded roles need further formal evaluation and replication across practice settings.
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Affiliation(s)
- Susan A Chapman
- S.A. Chapman is professor, Department of Social and Behavioral Sciences, School of Nursing, and faculty, Center for Health Professions and Institute for Health Policy Studies, University of California, San Francisco, San Francisco, California.A. Marks is a senior manager, Center for the Health Professions, University of California, San Francisco, San Francisco, California.C. Dower is health policy and law director, Center for the Health Professions, University of California, San Francisco, San Francisco, California
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Hill B, Richardson B, Skouteris H. Do We Know How to Design Effective Health Coaching Interventions: A Systematic Review of the State of the Literature. Am J Health Promot 2015; 29:e158-68. [DOI: 10.4278/ajhp.130510-lit-238] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective. To systematically review health coaching interventions regarding effectiveness of health coaching for specific outcomes, optimal intervention approaches, and identification of specific techniques associated with effectiveness. Data Source. Articles were sourced from CINAHL, Global Health, PsycINFO, Academic Search Complete, Health Source, Psychology and Behavioral Sciences Collection, and Medline. Study Inclusion and Exclusion Criteria. Randomized controlled trials were included if the study (1) employed health coaching according to a predefined criterion; (2) clearly reported the use of health coaching; or (3) incorporated the use of coaching. Data Extraction. Aims, participants, approach, behavior change techniques (BCTs), and findings pertaining to each study were summarized. BCTs were classified according to the CALO-RE taxonomy. Data Synthesis. Data were synthesized by cross-tabulation of BCTs with study outcomes. Results. Fifteen of 16 eligible studies reported a positive intervention effect in at least one outcome. Nine studies (56%) did not define health coaching; the number of intervention sessions provided ranged from 2 to 48; and in three studies, one or more intervention details were unclear. It was hence difficult to synthesize the studies to adequately address our research questions. Conclusion. Health coaching is a promising strategy for health improvements; however, future research should ensure clarity in reporting intervention details, clearer definitions of health coaching/theoretical bases, consistency in reporting BCTs, and the inclusion of process variables as outcome measures.
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Frontline experiences of a practice redesign to improve self-management of obesity in safety net clinics. J Ambul Care Manage 2015; 38:153-63. [PMID: 25748264 DOI: 10.1097/jac.0000000000000063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Teamlets of physicians and medical assistants may help improve obesity management in primary care settings. We aimed to understand the barriers and facilitators of implementing a teamlet approach to managing obesity in 3 safety net clinics. Key stakeholder interviews (n = 21) were conducted both during early implementation of practice change and 6 months later. Patient surveys (n = 393) examined obese patient activation and health status. Insufficient program resources and limited patient engagement due to external factors were implementation barriers despite fairly high patient activation. Staff members need time and resources to execute new responsibilities to support obesity management in safety net settings. Because of high turnover, multiple supporters may improve sustainability.
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Willard-Grace R, Chen EH, Hessler D, DeVore D, Prado C, Bodenheimer T, Thom DH. Health coaching by medical assistants to improve control of diabetes, hypertension, and hyperlipidemia in low-income patients: a randomized controlled trial. Ann Fam Med 2015; 13:130-8. [PMID: 25755034 PMCID: PMC4369595 DOI: 10.1370/afm.1768] [Citation(s) in RCA: 97] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
PURPOSE Health coaching by medical assistants could be a financially viable model for providing self-management support in primary care if its effectiveness were demonstrated. We investigated whether in-clinic health coaching by medical assistants improves control of cardiovascular and metabolic risk factors when compared with usual care. METHODS We conducted a 12-month randomized controlled trial of 441 patients at 2 safety net primary care clinics in San Francisco, California. The primary outcome was a composite measure of being at or below goal at 12 months for at least 1 of 3 uncontrolled conditions at baseline as defined by hemoglobin A1c, systolic blood pressure, and low-density lipoprotein (LDL) cholesterol. Secondary outcomes were meeting all 3 goals and meeting individual goals. Data were analyzed using χ(2) tests and linear regression models. RESULTS Participants in the coaching arm were more likely to achieve both the primary composite measure of 1 of the clinical goals (46.4% vs 34.3%, P = .02) and the secondary composite measure of reaching all clinical goals (34.0% vs 24.7%, P = .05). Almost twice as many coached patients achieved the hemoglobin A1c goal (48.6% vs 27.6%, P = .01). At the larger study site, coached patients were more likely to achieve the LDL cholesterol goal (41.8% vs 25.4%, P = .04). The proportion of patients meeting the systolic blood pressure goal did not differ significantly. CONCLUSIONS Medical assistants serving as in-clinic health coaches improved control of hemoglobin A1c and LDL levels, but not blood pressure, compared with usual care. Our results highlight the need to understand the relationship between patients' clinical conditions, interventions, and the contextual features of implementation.
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Affiliation(s)
- Rachel Willard-Grace
- Department of Family and Community Medicine, University of California San Francisco, San Francisco, California
| | - Ellen H Chen
- Department of Family and Community Medicine, University of California San Francisco, San Francisco, California Silver Avenue Family Health Center, San Francisco Department of Public Health, San Francisco, California
| | - Danielle Hessler
- Department of Family and Community Medicine, University of California San Francisco, San Francisco, California
| | - Denise DeVore
- Department of Family and Community Medicine, University of California San Francisco, San Francisco, California
| | - Camille Prado
- Department of Family and Community Medicine, University of California San Francisco, San Francisco, California
| | - Thomas Bodenheimer
- Department of Family and Community Medicine, University of California San Francisco, San Francisco, California
| | - David H Thom
- Department of Family and Community Medicine, University of California San Francisco, San Francisco, California
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Van der Wees PJ, Friedberg MW, Guzman EA, Ayanian JZ, Rodriguez HP. Comparing the implementation of team approaches for improving diabetes care in community health centers. BMC Health Serv Res 2014; 14:608. [PMID: 25468448 PMCID: PMC4264557 DOI: 10.1186/s12913-014-0608-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Accepted: 11/17/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patient panel management and community-based care management may be viable strategies for community health centers to improve the quality of diabetes care for vulnerable patient populations. The objective of our study was to clarify implementation processes and experiences of integrating office-based medical assistant (MA) panel management and community health worker (CHW) community-based management into routine care for diabetic patients. METHODS Mixed methods study with interviews and surveys of clinicians and staff participating in a study comparing the effectiveness of MA and CHW health coaching for improving diabetes care. Participants included 24 key informants in five role categories and 249 clinicians and staff survey respondents from 14 participating practices. We conducted thematic analyses of key informant interview transcripts to clarify implementation processes and describe barriers to integrating the new roles into practice. We surveyed clinicians and staff to assess differences in practice culture among intervention and control groups. We triangulated findings to identify concordant and disparate results across data sources. RESULTS Implementation processes and experiences varied considerably among the practices implementing CHW and MA team-based approaches, resulting in differences in the organization of health coaching and self-management support activities. Importantly, CHW and MA responsibilities converged over time to focus on health coaching of diabetic patients. MA health coaches experienced difficulty in allocating dedicated time due to other MA responsibilities that often crowded out time for diabetic patient health coaching. Time constraints also limited the personal introduction of patients to health coaches by clinicians. Participants highlighted the importance of a supportive team climate and proactive leadership as important enablers for MAs and CHWs to implement their health coaching responsibilities and also promoted professional growth. CONCLUSION Implementation of team-based strategies to improve diabetes care for vulnerable populations was diverse, however all practices converged in their foci on health coaching roles of CHWs and MAs. Our study suggests that a flexible approach to implementing health coaching is more important than fidelity to rigid models that do not allow for variable allocation of responsibilities across team members. Clinicians play an instrumental role in supporting health coaches to grow into their new patient care responsibilities.
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Affiliation(s)
- Philip J Van der Wees
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA. .,Scientific Institute for Quality of Healthcare, Radboud University Medical Center, Nijmegen, the Netherlands. .,The RAND Corporation, Boston, MA, USA.
| | - Mark W Friedberg
- The RAND Corporation, Boston, MA, USA. .,Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA.
| | | | - John Z Ayanian
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA. .,Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA. .,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.
| | - Hector P Rodriguez
- Division of Health Policy and Management, University of California, Berkeley 50 University Hall, Room 245, Berkeley, CA, 94720, USA.
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Grace SM, Rich J, Chin W, Rodriguez HP. Fidelity of implementation to a care team redesign and improved outcomes of diabetes care. Int J Qual Health Care 2014; 27:60-6. [PMID: 25431469 DOI: 10.1093/intqhc/mzu088] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE We assessed fidelity of implementation (FOI) to the intended features of a primary care team redesign that integrated registered nurse care managers and patient health coaches onto existing care teams. The relation of FOI ranking and improvements in intermediate outcomes of diabetes care was examined. DESIGN We assessed FOI by interviewing frontline primary care team members (n = 20). We explored the relation of FOI and outcomes of diabetes care (n = 10 206 patients) over a 3-year period (2010-12). Multilevel, multivariate regression estimated the relation of FOI and improvements in outcomes of diabetes care. SETTING Five primary care practices in greater Los Angeles, CA, USA. PARTICIPANTS Ten thousand, two hundred and six adult patients with diabetes; 20 frontline primary care clinicians and staff. MAIN OUTCOME MEASURES Blood pressure, hemoglobin A1c (HbA1c) and low-density lipoprotein cholesterol (LDL-C) control among adult diabetic patients. RESULTS All practices improved diabetic patients' LDL-C control over time. In adjusted analyses, the practice with the highest FOI achieved the largest improvement in blood pressure and HbA1c control among diabetic patients. In contrast, the practice with the lowest FOI had the least improvements in blood pressure, HbA1c and LDL-C control. FOI was an inconsistent predictor of intermediate outcomes of diabetes care for other practices. CONCLUSIONS FOI assessment can be useful for identifying low FOI to a redesign so that technical assistance and resources can be provided to improve team functioning and patient outcomes. High FOI can enable greater improvements in patient outcomes in the context of primary care practice redesign.
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Affiliation(s)
- Sherry M Grace
- Department of Health Policy and Management, UCLA Fielding School of Public Health, 650 Charles E Young Drive South, Los Angeles, CA 90095, USA
| | - Jeremy Rich
- HealthCare Partners Institute for Applied Research and Education, 19191 South Vermont Avenue, Suite 200, Torrance, CA 90502, USA
| | - William Chin
- HealthCare Partners Medial Group and Affiliated Physicians, 19191 South Vermont Avenue, Suite 200, Torrance, CA 90502, USA
| | - Hector P Rodriguez
- Division of Health Policy and Management, University of California, Berkeley School of Public Health, 50 University Hall, Room 245, Berkeley, CA 94720, USA
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Unverzagt S, Peinemann F, Oemler M, Braun K, Klement A. Meta-regression analyses to explain statistical heterogeneity in a systematic review of strategies for guideline implementation in primary health care. PLoS One 2014; 9:e110619. [PMID: 25343450 PMCID: PMC4208765 DOI: 10.1371/journal.pone.0110619] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Accepted: 09/15/2014] [Indexed: 11/18/2022] Open
Abstract
This study is an in-depth-analysis to explain statistical heterogeneity in a systematic review of implementation strategies to improve guideline adherence of primary care physicians in the treatment of patients with cardiovascular diseases. The systematic review included randomized controlled trials from a systematic search in MEDLINE, EMBASE, CENTRAL, conference proceedings and registers of ongoing studies. Implementation strategies were shown to be effective with substantial heterogeneity of treatment effects across all investigated strategies. Primary aim of this study was to explain different effects of eligible trials and to identify methodological and clinical effect modifiers. Random effects meta-regression models were used to simultaneously assess the influence of multimodal implementation strategies and effect modifiers on physician adherence. Effect modifiers included the staff responsible for implementation, level of prevention and definition pf the primary outcome, unit of randomization, duration of follow-up and risk of bias. Six clinical and methodological factors were investigated as potential effect modifiers of the efficacy of different implementation strategies on guideline adherence in primary care practices on the basis of information from 75 eligible trials. Five effect modifiers were able to explain a substantial amount of statistical heterogeneity. Physician adherence was improved by 62% (95% confidence interval (95% CI) 29 to 104%) or 29% (95% CI 5 to 60%) in trials where other non-medical professionals or nurses were included in the implementation process. Improvement of physician adherence was more successful in primary and secondary prevention of cardiovascular diseases by around 30% (30%; 95% CI -2 to 71% and 31%; 95% CI 9 to 57%, respectively) compared to tertiary prevention. This study aimed to identify effect modifiers of implementation strategies on physician adherence. Especially the cooperation of different health professionals in primary care practices might increase efficacy and guideline implementation seems to be more difficult in tertiary prevention of cardiovascular diseases.
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Affiliation(s)
- Susanne Unverzagt
- Institute of Medical Epidemiology, Biostatistics and Informatics, University Halle/Wittenberg, Halle (Saale), Germany
| | - Frank Peinemann
- Children's Hospital, University of Cologne, Cologne, Germany
| | - Matthias Oemler
- Section of General Practice, Institute of Medical Epidemiology, Biostatistics and Informatics, University Halle/Wittenberg, Halle (Saale), Germany
| | - Kristin Braun
- Section of General Practice, Institute of Medical Epidemiology, Biostatistics and Informatics, University Halle/Wittenberg, Halle (Saale), Germany
| | - Andreas Klement
- Section of General Practice, Institute of Medical Epidemiology, Biostatistics and Informatics, University Halle/Wittenberg, Halle (Saale), Germany
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Grant SJ, Bensoussan A. The process of care in integrative health care settings - a qualitative study of US practices. BMC COMPLEMENTARY AND ALTERNATIVE MEDICINE 2014; 14:410. [PMID: 25342101 PMCID: PMC4223759 DOI: 10.1186/1472-6882-14-410] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Accepted: 10/07/2014] [Indexed: 11/10/2022]
Abstract
BACKGROUND There is a lack of research on the organisational operations of integrative healthcare (IHC) practices. IHC is a therapeutic strategy integrating conventional and complementary medicine in a shared context to administer individualized treatment. To better understand the process of care in IHC - the way in which patients are triaged and treatment plans are constructed, interviews were conducted with integrative health care leaders and practitioners in the US. METHODS Semi-structured interviews were conducted with a pragmatic group of fourteen leaders and practitioners from nine different IHC settings. All interviews were conducted face-to-face with the exception of one phone interview. Questions focussed on understanding the "process of care" in an integrative healthcare setting. Deductive categories were formed from the aims of the study, focusing on: organisational structure, processes of care (subcategories: patient intake, treatment and charting, use of guidelines or protocols), prevalent diseases or conditions treated, and the role of research in the organisation. The similarities and differences of the ITH entities emerged from this process. RESULTS On an organisational level, conventional and CM services and therapies were co-located in all nine settings. For patients, this means there is more opportunity for 'seamless care'. Shared information systems enabled easy communication using internal messaging or email systems, and shared patient intake information. But beyond this infrastructure alignment for integrative health care was less supported. There were no use of protocols or guidelines within any centre, no patient monitoring mechanism beyond that which occurred within one-on-one appointments. Joint planning for a patient treatment was typically ad hoc through informal mechanisms. Additional duties typically come at a direct financial cost to fee-for-service practitioners. In contrast, service delivery and the process of care within hospital inpatient services followed a more formalised structure. CONCLUSIONS IHC is a complex, emerging field with divergent meanings and interpretations. The structures and processes of the IHC entities reported provide insight to the variable ways in which IHC manifests whilst commonly holding a similar vision. This report contributes to understanding IHC, providing evidence for future planning, implementation and evaluation to meet patient needs and demands in this area.
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Grace SM, Rich J, Chin W, Rodriguez HP. Implementing Interdisciplinary Teams Does Not Necessarily Improve Primary Care Practice Climate. Am J Med Qual 2014; 31:5-11. [PMID: 25214648 DOI: 10.1177/1062860614550333] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The complexity of successfully implementing interdisciplinary care team approaches in primary care has challenged many delivery system stakeholders. One-year changes in clinicians' and staff experiences of practice climate among 5 practices implementing interdisciplinary primary care teams and 28 other practices were compared. In adjusted analyses, practices implementing care teams reported improved team structure (78.0 in 2011 vs 79.3 in 2012), team functioning (75.7 vs 77.7), readiness for change (77.6 vs 77.7), and perceptions of skills and knowledge (48.0 vs 53.6) over time. However, the improvements were not significantly different from changes experienced by other practices. Achieving improvements in practice climate through care team redesign is challenging, even with structured learning opportunities for team members. Practice climate did not deteriorate over time, indicating that implementing a complex team redesign does not harm working relationships of frontline clinicians and staff.
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Affiliation(s)
| | - Jeremy Rich
- HealthCare Partners Institute for Applied Research and Education, Torrance, CA
| | - William Chin
- HealthCare Partners Affiliates Medical Group, Torrance, CA
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Pellico LH, Gilliam WP, Lee AW, Kerns RD. Hearing new voices: registered nurses and health technicians experience caring for chronic pain patients in primary care clinics. Open Nurs J 2014; 8:25-33. [PMID: 25246996 PMCID: PMC4168647 DOI: 10.2174/1874434601408010025] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Revised: 06/30/2014] [Accepted: 07/05/2014] [Indexed: 01/29/2023] Open
Abstract
Recent national estimates from the U.S. reveal that as many as one-third of all Americans experience chronic pain resulting in high prevalence rates of visits to primary care clinics (PCC). Indeed, chronic pain appears to be an emerging global health problem. Research has largely ignored the perspective of PCC staff other than physicians in providing care for patients with chronic pain. We wanted to gain insights from the experiences of Registered Nurses (RNs) and Health Technicians (HTs) who care for this patient population. Krippendorff’s method for content analysis was used to analyze comments written in an open-ended survey from fifty-seven primary care clinic staff (RNs-N=27 and HTs-N=30) respondents. This represented an overall response rate of 75%. Five themes emerged related to the experience of RNs and HTs caring for patients with chronic pain: 1) Primacy of Medications and Accompanying Clinical Quandaries; 2) System Barriers; 3) Dealing with Failure; 4) Primacy of Patient Centered Care; and 5) Importance of Team Based Care. This study demonstrates that nursing staff provide patient-centered care, recognize the importance of their role within an interdisciplinary team and can offer valuable insight about the care of patients with chronic pain. This study provides insight into strategies that can mitigate barriers to chronic pain management while sustaining those aspects that RNs and HTs view as essential for improving patient care for this vulnerable population in PCCs.
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Affiliation(s)
- Linda H Pellico
- Yale University School of Nursing, Yale University West Campus, P.O. Box 27399, West Haven, CT 06516-7399, USA
| | - Wesley P Gilliam
- Primary Care Mental Health Integration, VA New Mexico Health Care System, 1501 San Pedro S.E. MC 116, Albuquerque, NM 87108, USA
| | - Allison W Lee
- Yale School of Medicine and VA Connecticut Healthcare System, PRIME Center/11ACSLG, VA Connecticut Healthcare System, 950 Campbell Avenue, Building 35A, Rm 222, West Haven, CT 06516, USA
| | - Robert D Kerns
- VA Connecticut Healthcare System and Yale University, PRIME Center/11ACSLG, VA Connecticut Healthcare System, 950 Campbell Avenue, Building 35A, Rm 201, West Haven, CT 06516, USA
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Wodinski L, Woodman K, Wanke M, Nguyen T, Jacobs P. Implementing the Resource in Clinic Program in primary care delivery: a team-based dyad approach. J Prim Care Community Health 2014; 6:41-7. [PMID: 25027119 DOI: 10.1177/2150131914542437] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Alberta's Primary Care Networks (PCNs) bring together family physicians and other health professionals to provide local, comprehensive, and readily accessible primary care services to patients. The Edmonton North PCN, one of the largest in the province, piloted the Resource in Clinic (RIC) Program with objectives to increase efficiencies in the use of physician time, increase physician workplace satisfaction, increase unattached/orphan patient access, and decrease patient wait times. An evaluation of the RIC Program employed surveys (completed by physicians with RICs, RIC staff, and patients), log chart recording, and physician billing data and cost analysis. The findings indicated high satisfaction with the model, increased physician visits, and improved access for patient with comorbidities. The study did not demonstrate increased number of patients or new patients, nor could conclusions be drawn related to patient wait times.
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Affiliation(s)
| | - Kate Woodman
- Catalyst Research and Development Inc., Edmonton, Alberta, Canada
| | - Margaret Wanke
- Charis Management Consulting, Inc, Edmonton, Alberta, Canada
| | - Thanh Nguyen
- Institute of Health Economics, Edmonton, Alberta, Canada
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42
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Flexible implementation and integration of new team members to support patient-centered care. Healthcare (Basel) 2014; 2:145-51. [DOI: 10.1016/j.hjdsi.2014.02.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Revised: 02/03/2014] [Accepted: 02/11/2014] [Indexed: 11/22/2022] Open
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Proia KK, Thota AB, Njie GJ, Finnie RKC, Hopkins DP, Mukhtar Q, Pronk NP, Zeigler D, Kottke TE, Rask KJ, Lackland DT, Brooks JF, Braun LT, Cooksey T. Team-based care and improved blood pressure control: a community guide systematic review. Am J Prev Med 2014; 47:86-99. [PMID: 24933494 PMCID: PMC4672378 DOI: 10.1016/j.amepre.2014.03.004] [Citation(s) in RCA: 166] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2013] [Revised: 02/17/2014] [Accepted: 03/12/2014] [Indexed: 01/17/2023]
Abstract
CONTEXT Uncontrolled hypertension remains a widely prevalent cardiovascular risk factor in the U.S. team-based care, established by adding new staff or changing the roles of existing staff such as nurses and pharmacists to work with a primary care provider and the patient. Team-based care has the potential to improve the quality of hypertension management. The goal of this Community Guide systematic review was to examine the effectiveness of team-based care in improving blood pressure (BP) outcomes. EVIDENCE ACQUISITION An existing systematic review (search period, January 1980-July 2003) assessing team-based care for BP control was supplemented with a Community Guide update (January 2003-May 2012). For the Community Guide update, two reviewers independently abstracted data and assessed quality of eligible studies. EVIDENCE SYNTHESIS Twenty-eight studies in the prior review (1980-2003) and an additional 52 studies from the Community Guide update (2003-2012) qualified for inclusion. Results from both bodies of evidence suggest that team-based care is effective in improving BP outcomes. From the update, the proportion of patients with controlled BP improved (median increase=12 percentage points); systolic BP decreased (median reduction=5.4 mmHg); and diastolic BP also decreased (median reduction=1.8 mmHg). CONCLUSIONS Team-based care increased the proportion of people with controlled BP and reduced both systolic and diastolic BP, especially when pharmacists and nurses were part of the team. Findings are applicable to a range of U.S. settings and population groups. Implementation of this multidisciplinary approach will require health system-level organizational changes and could be an important element of the medical home.
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Affiliation(s)
- Krista K Proia
- Community Guide Branch, Division of Epidemiology, Analysis, and Library Services, Center for Surveillance, Epidemiology, and Laboratory Services, CDC
| | - Anilkrishna B Thota
- Community Guide Branch, Division of Epidemiology, Analysis, and Library Services, Center for Surveillance, Epidemiology, and Laboratory Services, CDC.
| | - Gibril J Njie
- Community Guide Branch, Division of Epidemiology, Analysis, and Library Services, Center for Surveillance, Epidemiology, and Laboratory Services, CDC
| | - Ramona K C Finnie
- Community Guide Branch, Division of Epidemiology, Analysis, and Library Services, Center for Surveillance, Epidemiology, and Laboratory Services, CDC
| | - David P Hopkins
- Community Guide Branch, Division of Epidemiology, Analysis, and Library Services, Center for Surveillance, Epidemiology, and Laboratory Services, CDC
| | - Qaiser Mukhtar
- Community Guide Branch, Division of Epidemiology, Analysis, and Library Services, Center for Surveillance, Epidemiology, and Laboratory Services, CDC
| | | | | | | | - Kimberly J Rask
- Emory University, Georgia Medical Care Foundation, Atlanta, Georgia
| | | | - Joy F Brooks
- South Carolina Department of Health & Environmental Control, Columbia
| | | | - Tonya Cooksey
- Community Guide Branch, Division of Epidemiology, Analysis, and Library Services, Center for Surveillance, Epidemiology, and Laboratory Services, CDC
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Moreno G, Gold J, Mavrinac M. Primary care residents want to learn about the patient-centered medical home. Fam Med 2014; 46:539-543. [PMID: 25058548 PMCID: PMC4122249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND AND OBJECTIVES The patient-centered medical home (PCMH) is an important model of primary care with a promise of improving quality, reducing costs, and improving patient satisfaction. Many primary care residency programs have PCMH initiatives, but it is unclear if residents are interested in learning more about the PCMH. Our objective was to examine primary care residents' attitudes and knowledge about the PCMH model and how it relates to them. METHODS A total of 82 first- through third-year family medicine and internal medicine residents participated in a survey with 25 questions. Descriptive statistics were performed to describe the responses. RESULTS The survey response rate was 91%. Sixty-one percent of residents thought they had "poor" or "fair" knowledge of the PCMH, and 84% thought it was important to be knowledgeable about the PCMH. Thirty-four percent rated their ability to describe the PCMH as "well" or "very well." Eighty-six percent thought they learned "too little" or "way too little" about the PCMH during medical school. The majority (88%) of residents were interested in learning more about the PCMH. CONCLUSIONS Family and internal medicine residents are interested in learning more about the PCMH during residency. Residents may benefit from experiential learning that focuses on the PCMH.
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Affiliation(s)
- Gerardo Moreno
- Department of Family Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
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Knierim KE, Fernald DH, Staton EW, Nease DE. Organizing Your Practice for Screening and Secondary Prevention Among Adults. Prim Care 2014; 41:163-83. [DOI: 10.1016/j.pop.2014.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Patient- and family-centered care coordination: a framework for integrating care for children and youth across multiple systems. Pediatrics 2014; 133:e1451-60. [PMID: 24777209 DOI: 10.1542/peds.2014-0318] [Citation(s) in RCA: 197] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Understanding a care coordination framework, its functions, and its effects on children and families is critical for patients and families themselves, as well as for pediatricians, pediatric medical subspecialists/surgical specialists, and anyone providing services to children and families. Care coordination is an essential element of a transformed American health care delivery system that emphasizes optimal quality and cost outcomes, addresses family-centered care, and calls for partnership across various settings and communities. High-quality, cost-effective health care requires that the delivery system include elements for the provision of services supporting the coordination of care across settings and professionals. This requirement of supporting coordination of care is generally true for health systems providing care for all children and youth but especially for those with special health care needs. At the foundation of an efficient and effective system of care delivery is the patient-/family-centered medical home. From its inception, the medical home has had care coordination as a core element. In general, optimal outcomes for children and youth, especially those with special health care needs, require interfacing among multiple care systems and individuals, including the following: medical, social, and behavioral professionals; the educational system; payers; medical equipment providers; home care agencies; advocacy groups; needed supportive therapies/services; and families. Coordination of care across settings permits an integration of services that is centered on the comprehensive needs of the patient and family, leading to decreased health care costs, reduction in fragmented care, and improvement in the patient/family experience of care.
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47
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Jaruseviciene L, Liseckiene I, Valius L, Kontrimiene A, Jarusevicius G, Lapão LV. Teamwork in primary care: perspectives of general practitioners and community nurses in Lithuania. BMC FAMILY PRACTICE 2013; 14:118. [PMID: 23945286 PMCID: PMC3751467 DOI: 10.1186/1471-2296-14-118] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Accepted: 08/12/2013] [Indexed: 11/21/2022]
Abstract
BACKGROUND A team approach in primary care has proven benefits in achieving better outcomes, reducing health care costs, satisfying patient needs, ensuring continuity of care, increasing job satisfaction among health providers and using human health care resources more efficiently. However, some research indicates constraints in collaboration within primary health care (PHC) teams in Lithuania. The aim of this study was to gain a better understanding of the phenomenon of teamwork in Lithuania by exploring the experiences of teamwork by general practitioners (GPs) and community nurses (CNs) involved in PHC. METHODS Six focus groups were formed with 29 GPs and 27 CNs from the Kaunas Region of Lithuania. Discussions were recorded and transcribed verbatim. A thematic analysis of these data was then performed. RESULTS The analysis of focus group data identified six thematic categories related to teamwork in PHC: the structure of a PHC team, synergy among PHC team members, descriptions of roles and responsibilities of team members, competencies of PHC team members, communications between PHC team members and the organisational background for teamwork. These findings provide the basis for a discussion of a thematic model of teamwork that embraces formal, individual and organisational factors. CONCLUSIONS The need for effective teamwork in PHC is an issue receiving broad consensus; however, the process of teambuilding is often taken for granted in the PHC sector in Lithuania. This study suggests that both formal and individual behavioural factors should be targeted when aiming to strengthen PHC teams. Furthermore, this study underscores the need to provide explicit formal descriptions of the roles and responsibilities of PHC team members in Lithuania, which would include establishing clear professional boundaries. The training of team members is an essential component of the teambuilding process, but not sufficient by itself.
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Affiliation(s)
- Lina Jaruseviciene
- Department of Family Medicine, Lithuanian University of Health Sciences (LUHS), Mickeviciaus 9, Kaunas LT 44307, Lithuania
| | - Ida Liseckiene
- Department of Family Medicine, Lithuanian University of Health Sciences (LUHS), Mickeviciaus 9, Kaunas LT 44307, Lithuania
| | - Leonas Valius
- Department of Family Medicine, Lithuanian University of Health Sciences (LUHS), Mickeviciaus 9, Kaunas LT 44307, Lithuania
| | - Ausrine Kontrimiene
- Department of Family Medicine, Lithuanian University of Health Sciences (LUHS), Mickeviciaus 9, Kaunas LT 44307, Lithuania
| | - Gediminas Jarusevicius
- Department of Cardiology, Lithuanian University of Health Sciences, Mickeviciaus 9, Kaunas LT 44307, Lithuania
| | - Luís Velez Lapão
- WHO Collaborating Center for Health Workforce Policy and Planning, Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Portugal, Rua da Junqueira 100, Lisbon 1349-008, Portugal
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Moskowitz D, Thom DH, Hessler D, Ghorob A, Bodenheimer T. Peer coaching to improve diabetes self-management: which patients benefit most? J Gen Intern Med 2013; 28:938-42. [PMID: 23404203 PMCID: PMC3682027 DOI: 10.1007/s11606-013-2367-7] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2012] [Revised: 01/02/2013] [Accepted: 01/22/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND Peer health coaching is an effective method of enhancing self-management support in patients with diabetes. It is unclear whether peer health coaching is equally beneficial to all patients with poor glycemic control, or is most effective for subgroups of patients. OBJECTIVE To examine whether the effect of peer health coaching on hemoglobin A1c (A1c) is modified by characteristics that are known to be associated with diabetes control. DESIGN Sub-group analyses of randomized control trial. PARTICIPANTS Two hundred and ninety nine patients with diabetes receiving care in public health clinics who participated in a randomized controlled trial of peer health coaches. MAIN MEASURES We examined whether the association between study group and change in A1c was modified by differences in patients' demographic, behavioral or psychosocial characteristics. Analyses were adjusted for co-variables associated with change in A1c. KEY RESULTS The effect of coaching on patient A1c was modified by patients' level of self-management and degree of medication adherence as baseline (p=.02, and p=.03 respectively in adjusted models). For participants with "low" self-management (one standard deviation below the mean score), the usual care group experienced a slight increase in A1c (0.3 %), while the health coaching group experienced a decrease (-0.9 %). For participants with "high" self-management (one standard deviation above the mean score), both groups experienced a similar decrease in A1c (usual care group: -1.0 %; health coaching group: -1.1 %). Participants with "low" medication adherence in the usual care group experienced an increase in A1c (0.5 %), while the health coaching group experienced a decrease (-0.8 %). Participants with "high" medication adherence experienced similar decreases (usual care group: -1.1 %; health coaching group: -1.3 %). CONCLUSION Peer health coaching had a larger effect on lowering A1c in patients with low levels of medication adherence and self-management support than in patients with higher levels. Peer health coaching interventions may be most effective if targeted to high-risk patients with diabetes with poor glycemic control and with poor self-management and medication adherence.
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Affiliation(s)
- David Moskowitz
- Department of Ambulatory and Preventive Medicine, Alameda County Medical Center, 1411 East 31st St, Oakland, CA, 94602, USA.
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Willard-Grace R, DeVore D, Chen EH, Hessler D, Bodenheimer T, Thom DH. The effectiveness of medical assistant health coaching for low-income patients with uncontrolled diabetes, hypertension, and hyperlipidemia: protocol for a randomized controlled trial and baseline characteristics of the study population. BMC FAMILY PRACTICE 2013; 14:27. [PMID: 23433349 PMCID: PMC3616979 DOI: 10.1186/1471-2296-14-27] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/19/2012] [Accepted: 02/08/2013] [Indexed: 01/13/2023]
Abstract
BACKGROUND Many patients with chronic disease do not reach goals for management of their conditions. Self-management support provided by medical assistant health coaches within the clinical setting may help to improve clinical outcomes, but most studies to date lack statistical power or methodological rigor. Barriers to large scale implementation of the medical assistant coach model include lack of clinician buy-in and the absence of a business model that will make medical assistant health coaching sustainable. This study will add to the evidence base by determining the effectiveness of health coaching by medical assistants on clinical outcomes and patient self-management, by assessing the impact of health coaching on the clinician experience, and by examining the costs and potential savings of health coaching. METHODS/DESIGN This randomized controlled trial will evaluate the effectiveness of clinic-based medical assistant health coaches to improve clinical outcomes and self-management skills among low-income patients with uncontrolled type 2 diabetes, hypertension, or hyperlipidemia. A total of 441 patients from two San Francisco primary care clinics have been enrolled and randomized to receive a health coach (n = 224) or usual care (n = 217). Patients participating in the health coaching group will receive coaching for 12 months from medical assistants trained as health coaches. The primary outcome is a change in hemoglobin A1c, systolic blood pressure, or LDL cholesterol among patients with uncontrolled diabetes, hypertension and hyperlipidemia, respectively. Self-management behaviors, perceptions of the health care team and clinician, BMI, and chronic disease self-efficacy will be measured at baseline and after 12 months. Clinician experience is being assessed through surveys and qualitative interviews. Cost and utilization data will be analyzed through cost-predictive models. DISCUSSION Medical assistants are an untapped resource to provide self-management support for patients with uncontrolled chronic disease. Having successfully completed recruitment, this study is uniquely poised to assess the effectiveness of the medical assistant health coaching model, to describe barriers and facilitators to implementation, and to develop a business case for sustainability. TRIAL REGISTRATION ClinicalTrials.gov identifier NCT-01220336.
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Affiliation(s)
- Rachel Willard-Grace
- Department of Family and Community Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Denise DeVore
- Department of Family and Community Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Ellen H Chen
- Department of Family and Community Medicine, University of California San Francisco, San Francisco, CA, USA
- San Francisco Department of Public Health, Silver Avenue Family Health Center, San Francisco, CA, USA
| | - Danielle Hessler
- Department of Family and Community Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Thomas Bodenheimer
- Department of Family and Community Medicine, University of California San Francisco, San Francisco, CA, USA
| | - David H Thom
- Department of Family and Community Medicine, University of California San Francisco, San Francisco, CA, USA
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Tomblin Murphy G, MacKenzie A, Alder R, Cruickshank C. Evaluation of a changed model of care delivery in a Canadian province using outcome mapping. Int J Health Plann Manage 2012; 28:346-66. [PMID: 23280769 DOI: 10.1002/hpm.2157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2012] [Revised: 11/15/2012] [Accepted: 11/20/2012] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Collaboration between the Nova Scotia Department of Health and Wellness, the province's District Health Authorities (DHAs) and the Izaak Walton Killam (IWK) Health Center led to the development and implementation of a new collaborative model of patient-centered care delivery in the province. OBJECTIVE The objective was to determine the effectiveness of the initiative in arriving at the envisioned care model by investigating its impacts (if any) on patient, system, and providers outcomes. METHODS A repeated surveys study design with mixed methods in an outcome mapping framework was used to measure process and outcome indicators for patients and families, providers, and the system. RESULTS Almost all outcomes at the patient and family, provider, and system level improved following the implementation of the model, and these effects were stronger on units where the model was more fully implemented. CONCLUSIONS The efforts of the province, DHAs and IWK to improve patient care through the new care model have been successful. This evaluation is unique in the broad range of indicators it incorporates. Comprehensive monitoring and evaluation of health system changes is critical to system effectiveness.
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Affiliation(s)
- Gail Tomblin Murphy
- Dalhousie University-WHO Collaborating Centre on Health Workforce Planning & Research, Halifax, Nova Scotia, Canada
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